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University of Louisville

Dept. of Justice Administration

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Internship/Practicum Application JA 450/690
(3 or 6 Credit Hours)

Full Name or Name you use: (Required)

e-mail (Required)

Home Address (Required)

Local Address (Required)

Home Phone #

Cell Phone #

UofL Student ID# (Required)

Have you every been convicted of a Felony? (Required)

Yes
No

If yes, explain:

Are you an U.S. Citizen? (Required)

Yes
No

Agency Preference:

List the agency title and city of the three most preferred placements. (Agency Placement to be Completed by Dr. Foster)

Date of Birth (ex. 01/01/1999) (Required)

Driver License Number (Required)

Drivers License State (Required)

Intern/Practicum Enrollment semester(s) (check all that apply) (Required)

SUMMER 2007
FALL 2007
SPRING 2008
SUMMER 2008
FALL 2008

Number of credits completed to date: (Required)

GPA (Required)

Experience:

What courses have you taken that would assist you in this placement? List significant work experience. Include Volunteer work.

Electronic Signature (ex. John Doe): (Required)

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